Respiratory Exam Concept Synthesis

What is the normal progression of ARDS? 1. Initiation of ARDS 2. Onset of pulmonary edema 3. End-stage ARDS 4. Alveolar collapse

1, 2, 4, 3

The physician orders dopamine at 2 mcg/kg/min for a patient who weighs 80 kg. The pharmacy sends an IV of 400 mg of Dopamine in 500 ml D5W. What rate will the nurse set on the IV pump in ml/hr? Whole number answer only.

12

The pharmacy delivers a Levophed Drip to be started on a hypotensive patient mixed as follows 2 mg of Levophed in 250 ml of D5W. How many micrograms of Levophed are in the 250 ml of D5W?

2,000

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation? When the low pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? A. Excessive airway secretions B. A leak within the ventilators circularity C. Decreased lung compliance D. The client is coughing or attempting to talk

B

A nurse is caring for a client who is experiencing acute opioid toxicity. What is the priority nursing intervention? A. Insert a large bore IV B. Ensure adequate airway C. Obtain an accurate medication history D. Prepare to administer an antagonist

B

The pharmacy delivers a Levophed Drip to be started on a hypotensive patient mixed as follows 2 mg of Levophed in 1,000 ml of D5W. The physician orders the patient to receive 1 mcg/min rate in ml/hour is?

30

The physician orders dopamine at 5 mcg/kg/min for a patient who weighs 80 kg. The pharmacy sends an IV of 400 mg of Dopamine in 500 ml D5W. What rate in ml/hour would the nurse set the infusion pump? Put the whole number only as the answer.

30

A nurse is caring for an elderly patient diagnosed with pneumonia. The patient has been ill for three days and the nurse suspects that the patient is dehydrated. Which of the following laboratory values would support this suspicion; A. WBC 11% B. Hematocrit of 60% C. Potassium of 3.5 D. Sodium of 132

B

The pharmacy delivers a Levophed Drip to be started on a hypotensive patient mixed as follows 2 mg of Levophed in 250 ml of D5W. The drip concentration would be what in ug/ml?

8

The physician orders dopamine at 5 mcg/kg/min for a patient who weighs 80 kg. The pharmacy sends an IV of 400 mg of Dopamine in 500 ml D5W. What is the drip concentration in ug/ml in its lowest form? Put the whole number only as the answer.

800

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate a bag-valve-mask ventilation B. Provide the client with a communication board C. obtain a blood sample for ABG analysis D. Document the ventilator settings

A

A patient has a Ph of 7.30, PCO2 of 60, PO2 of 55, HCO3- of 23. The would interpret this ABG as which of the following: A. Respiratory Acidosis B. Metabolic Alkalosis C. Metabolic Acidosis D. Repiratory Alkalosis

A

The most common early clinical manifestations of ARDS that the nurse may observe: A. dyspnea and tachypnea. B. cyanosis and apprehension. C. hypotension and tachycardia. D. respiratory distress and frothy sputum.

A

In which phase of acute respiratory distress syndrome (ARDS) does atelectasis occur due to decreased synthesis of surfactant and inactivation of existing surfactant? A. Injury B. Fibrotic C. Proliferative D. Refractory hypoxemic

A Rationale: During the injury phase (exudative phase), atelectasis occurs due to decreased synthesis of surfactant and inactivation of existing surfactant. During the proliferative phase, the inflammatory response occurs and there is an increased pulmonary vascular resistance, which may cause pulmonary hypertension. The fibrotic phase is characterized by remodeling of the lung with collagenous and fibrous tissues. Refractory hypoxemia occurs during the injury (exudative) phase, characterized by a severe V/Q mismatch and shunting of pulmonary capillary blood, which results in hypoxemia unresponsive to increasing concentrations of oxygen.

A nurse in the ED is assessing a patient for a closed pneumothorax and significant bruising on the left chest following a MVC. The client reports sever left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of a pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi

A Rationale: A client who has a pneumothorax experiences severely diminished pr absent breath sounds on the affected side.

A patient diagnosed with acute respiratory distress syndrome is being mechanically ventilated with 12 cm of positive end-expiratory pressure (PEEP). Upon assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. What is the most likely cause for this finding? A. Pneumothorax B. Decreased cardiac output C. Deterioration of the disease D. Obstructed endotracheal tube

A Rationale: A complication of PEEP may be a pneumothorax as a result of over-distention of the alveoli. If deterioration of the disease were the cause, both lung sounds would be decreased equally. Decreased cardiac output would affect vital signs, but not breath sounds. An obstructed endotracheal tube would affect both lung fields.

The nurse concludes that a patient is experiencing severe respiratory distress based on what assessment finding? A. The patient sits in tripod position. B. The patient reports difficulty sleeping. C. The patient walks restlessly in the room. D. The patient uses long sentences when conversing.

A Rationale: A patient with severe respiratory distress most commonly uses the tripod position to help decrease the work of breathing and reduces respiratory distress. The patient with severe respiratory distress has severe dyspnea; therefore, the patient would only be able to speak two to three words. The patient with severe respiratory distress would experience shortness of breath and may not be able to walk. Difficulty in sleeping can have many causes and does not necessarily indicate respiratory distress.

The patient progressed from acute lung injury to acute respiratory distress syndrome (ARDS). He is on the ventilator & receiving propofol(Diprivan) for sedation & fentanyl (Sublimaze) to decrease anxiety, agitation, & pain in order to decrease his work of breathing, O2 consumption, CO2 production & risk of injury. What intervention is recommended in caring for this patient? A. A sedation holiday B. Monitoring for hyper metabolism C. Keeping his legs still to avoid dislodging the airway D. Repositioning him every 4 hours to decrease agitation

A Rationale: A sedation holiday is needed to assess the patient's condition and readiness to extubate. A hypermetabolic state occurs with critical illness. With malnourished patients, enteral or parenteral nutrition is started within 24 hours; with well-nourished patients it is started within 3 days. With these medications, the patient will be assessed for cardiopulmonary depression. Venous thromboembolism prophylaxis will be used but there is no reason to keep the legs still. Repositioning the patient every 2 hours may help to decrease discomfort and agitation.

The nurse is caring for a patient with lung injury that has increased capillary permeability. What findings does the nurse anticipate in this patient? A. Pulmonary edema B. Pulmonary fibrosis C. Pulmonary embolus D. Pulmonary barotrauma

A Rationale: An increase in pulmonary capillary permeability results in fluid formation in the lungs, which causes pulmonary edema. In the reparative phase of acute respiratory failure, the diseased lung becomes dense with fibrous tissue, resulting in hypoxemia. Hypoxemia leads to fibrosis when it worsens and if the phase continues. Pulmonary embolus is a respiratory complication associated with acute respiratory distress syndrome. Alveolar over-distension during mechanical ventilation results in barotrauma.

The best patient response to treatment of ARDS occurs when initial management includes: A. Treatment of the underlying condition B. Administration of prophylactic antibiotics C. Treatment with diuretics and mild fluid restriction D. Endotracheal intubation and mechanical ventilation

A Rationale: Because ARDS is precipitated by a physiologic insult, a critical factor in its prevention and early management is treatment of the underlying condition. Prophylactic antibiotics, treatment with diuretics and fluid restriction, and mechanical ventilation are also used as ARDS progresses.

Which assessment finding should cause the nurse to suspect the early onset of hypoxemia? A. Restlessness B. Hypotension C. Central cyanosis D. Cardiac dysrhythmias

A Rationale: Because the brain is very sensitive to a decrease inoxygen delivery, restlessness, agitation, disorientation,and confusion are early signs of hypoxemia, for which thenurse should be alert. Mild hypertension is also an earlysign, accompanied by tachycardia. Central cyanosis is an unreliable, late sign of hypoxemia. Cardiac dysrhythmias also occur later

When admitting a patient with possible respiratory failure with a high PaCO2, which assessment information should be immediately reported to the health care provider? A. The patient is somnolent. (sleepy, drowsy) B. The patient complains of weakness. C. The patient's blood pressure is 164/98. D. The patient's oxygen saturation is 90%.

A Rationale: Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

A patient has acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure most likely would be implemented to maintain cardiac output? A. Administer crystalloid fluids or colloid solutions. B. Position the patient in the Trendelenburg position. C. Place the patient on fluid restriction and administer diuretics. D. Perform chest physiotherapy and assist with staged coughing.

A Rationale: Low cardiac output may necessitate crystalloid fluids or colloid solutions in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis would be inappropriate interventions.

The nurse assesses a patient admitted two days ago with a diagnosis of chest trauma after a motor vehicle accident. Oxygen is being delivered at 60% by way of Venturi mask. Which assessment finding indicates the development of acute respiratory distress syndrome? A. Progressive hypoxemia B. Increase in urine specific gravity C. Bilateral wheezing and stridor on auscultation D. Mild dyspnea that resolves when the patient is placed in high Fowler's position

A Rationale: One of the main characteristics of adult respiratory distress syndrome (ARDS) is worsening hypoxemia despite increased delivery of higher concentrations of oxygen. An increase in urine specific gravity is not associated with ARDS. Wheezing and stridor and dyspnea may be present and progress to respiratory distress in the patient with ARDS.

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by non rebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of ARDS? A. Tympatic temperature of 100.4F B. PaO2 50mm Hg C. Rhonchi D. Hypopnea

B

When mechanical ventilation is used for the patient with ARDS, what is the rationale for applying positive end-expiratory pressure (PEEP)? A. Prevent alveolar collapse and open up collapsed alveoli B. Permit smaller tidal volumes with permissive hypercapnia C. Promote complete emptying of the lungs during exhalation D. Permit extracorporeal oxygenation and carbon dioxide removal outside the body

A Rationale: Positive end-expiratory pressure (PEEP) used with mechanical ventilation applies positive pressure to the airway and lungs at the end of exhalation, keeping the lung partially expanded and preventing collapse of the alveoli and helping to open up collapsed alveoli. Permissive hypercapnia is allowed when the patient with ARDS is ventilated with smaller tidal volumes to prevent barotrauma. Extracorporeal membrane oxygenation and extracorporeal CO2 removal involve passing blood across a gas-exchanging membrane outside the body and then returning oxygenated blood to the body.

In caring for the patient with ARDS, what is the most characteristic sign the nurse would expect the patient to exhibit? A. Refractory hypoxemia B. Bronchial breath sounds C. Progressive hypercapnia D. Increased pulmonary artery wedge pressure (PAWP)

A Rationale: Refractory hypoxemia, hypoxemia that does not respond to increasing concentrations of oxygenation by any route, is a hallmark of ARDS and is always present. Bronchial breath sounds may be associated with the progression of ARDS. PaCO2 levels may be normal until the patient is no longer able to compensate in response to the hypoxemia. Pulmonary artery wedge pressure (PAWP) that is normally elevated in cardiogenic pulmonary edema is normal in the pulmonary edema of ARDS

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume

A Rationale: Vital lung capacity measures the amount of air the client can exhale after maximum inhalation. Functional residual capacity measures the amount of air in the lungs after normal expiration. Residual volume measures the amount of air in the lungs after forced expiration.

A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote improved V/Q matching, how should the nurse position the patient? A. On the left side B. On the right side C. In a reclining chair bed D. Supine with the head of the bed elevated

A Rationale: When there is impaired function of one lung, the patient should be positioned with the unaffected lung in the dependent position to promote perfusion to the functioning tissue. If the diseased lung is positioned dependently, more V/Q mismatch would occur. The head of the bed may be elevated or a reclining chair may be used, with the patient positioned on the unaffected side, to maximize thoracic expansion if the patient has increased work of breathing.

A nurse is caring for a client immediately after extubation. Which of the following manifestations indicates the nurse should call the rapid response team? A. Stridor B. Coughing C. Hoarseness D. Extensive oral secretions

A Rationale: stridor can indicate laryngeal edema and/or an impending airway obstruction.

The nurse is caring for a patient receiving mechanical ventilation with high levels of positive end-expiratory pressure (PEEP). What complication should the nurse monitor for in this patient? A. Barotrauma B. Oxygen toxicity C. Pneumoperitoneum D. Ventilator-associated pneumonia (VAP)

A Rationale: A high level of positive end-expiratory pressure (PEEP) leads to barotrauma due to the extreme inspiratory pressure. A patient is at risk for oxygen toxicity when there are respiratory complications caused by oxygen overdose. Pneumoperitoneum is a gastrointestinal complication. Prolonged mechanical ventilation also causes respiratory complication, such as ventilator-associated pneumonia (VAP).

The nurse is developing a plan of care for a patient with acute respiratory distress syndrome. What does the nurse determine to be the primary goal of oxygen therapy for the treatment of this patient? A. To correct hypoxemia B. To maintain fluid balance C. To maintain the cardiac output (CO) D. To increase the oxygen-carrying capacity of the blood

A Rationale: Oxygen therapy focuses on correction of hypoxemia. Oxygen is administered through masks with high-flow systems that deliver higher oxygen concentrations to maximize oxygen delivery. Nutritional therapy maintains good nutrition and fluid balance. Positive pressure ventilation is a respiratory therapy that provides further respiratory support and maintains cardiac output (CO). Transfusion of packed red blood cells increases hemoglobin, which in turn increases the oxygen carrying capacity of the blood.

Although ARDS may result from direct lung injury or indirect lung injury as a result of systemic inflammatory response syndrome (SIRS), the nurse is aware that ARDS is most likely to occur in the patient with a host insult resulting from: A. Sepsis. B. Oxygen toxicity C. Prolonged hypotension. D. Cardiopulmonary bypass.

A Rationale: Although ARDS may occur in the patient who has virtually any severe illness and may be both a cause and a result of systemic inflammatory response syndrome (SIRS), the most common precipitating insults of ARDS are sepsis, gastric aspiration, and severe massive trauma.

A nurse on the MedSurg Unit is assessing a client who recently transferred from the ICU following ET extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider? A. Increased coughing B. Diaphragmatic breathing C. Hemoptysis D. Kussmaul Respirations

A Rationale: other manifestations include an inability to cough up secretions and difficulty talking or breathing.

A patient has an ABG of 7.48, PCO2 of 32, PO2 of 120 and a HCO3 of 26. The nurse intreprets this ABG as which of the following? A. Metabolic Acidosis B. Respiratory Alkalosis C. Metabolic Alkalosis D. Respiratory Acidosis

B

The nurse is caring for a patient with acute respiratory distress syndrome (ARDS) in the fibrotic phase of the disorder. What clinical manifestations does the nurse anticipate the patient will exhibit? Select all that apply. A. Remodeled lung B. Deceased lung compliance C. Impairment of gas exchange D. Interstitial infiltrate on the chest x-ray E. Rhonchi sounds in lung auscultation

A, B, C Rationale: The fibrotic phase, also known as the chronic, or late, phase of acute respiratory distress syndrome (ARDS), occurs two to three weeks post-lung injury. The lung is completely remodeled by this time with dense and fibrous tissues. The scarring and fibrosis result in the decrease of lung compliance. Impairment in gas exchange is significant because the interstitium is fibrotic in nature. A chest x-ray may reveal least scattered interstitial infiltrates within the initial 24 hours. In the initial couple of hours, the patient's chest auscultation may reveal scattered to diffuse crackles and rhonchi breathing sounds.

A patient is recovering from acute respiratory distress syndrome (ARDS). What goals should a nurse have for this patient? Select all that apply. A. Clear lungs B. Patent airways C. PaO 2 within normal limits D. Arterial oxygen (PaO 2) above normal limits E. Oxygen saturation (SaO 2) greater than 90%

A, B, C, E Rationale: The goals for a patient recovering from ARDS are SaO 2 greater than 90%, patent airways, PaO 2 within normal limits for age or baseline values on room air, and clear lungs on auscultation. SaO 2 above 90% and PaO 2 within normal limits indicate satisfactory arterial oxygenation. Airways should be kept patent and clear of any secretions. Clear lungs indicate that there are no secretions obstructing the airway, and the lungs are functional. PaO 2 above normal levels means that the patient is hyperventilating.

A nurse assesses a patient with chronic lung disease and would expect to find which of the following symptoms? A. Clubbed fingers and toes B. Fatigue C. Confusion D. Lethargy

A, B, D

What patient positioning strategies should the nurse use while caring for a patient with acute respiratory distress syndrome (ARDS)? Select all that apply. A. Kinetic therapy B. Prone positioning C. Supine positioning D. Lateral positioning E. Continuous lateral rotation therapy

A, B, D Rationale: Some patients with ARDS have a marked improvement in arterial oxygen (PaO 2) when turned from the supine to the prone position with no change in fraction of inspired oxygen (FIO 2). Continuous lateral rotation therapy and kinetic therapy are other strategies that can be used for patients with ARDS. Continuous lateral rotation therapy involves continuous, slow, side-to-side turning of the patient by rotating the actual bed frame less than 40 degrees. Kinetic therapy involves rotating the patient side to side 40 degrees or more. In a supine position, the heart and the mediastinal mass may put pressure on the lungs, predisposing the patient to atelectasis. Therefore a supine position is not advisable. Lateral positioning is also not suitable because it may cause pooling of secretions.

Mark Donnelly is a 54 year old patient admitted 2 days ago in severe DT's. Immediately prior to his admission, he vomited, had a seizure, and probably aspirated. His previous medical history includes HTN, COPD, and an MI treated with angioplasty and a stent. According to his wife, he was taking Toprol and Lipitor regularly prior to admission and has smoked a pack a day for the past 30 years. He had been drinking a fifth of vodka daily until 3 days prior to admission when he stopped completely. He is 5'11" and weighs approximately 180 pounds. On arrival in the ED, his BP was 193/124 with a heart rate of 150. He was tremulous, nauseated, and agitated. Lorazepam was started according to CIWA protocol, but he began to vomit and had several seizures. What strategies will the nurse implement immediately to prevent ventilatory associated pneumonia? A. Raise the bed of the bed to 30-45 degrees B. Provide mouth care and tooth brushing according to protocol C. Suction the Et tube every 2 hours D. Suction the client orally as needed E. Suction the ET tube PRN when rhonchi are auscultated in the patients lungs F. Use the Ballard suction device

A, B, D, E, F,

What are the primary pathophysiologic changes that occur in the injury (exudative phase) of ARDS? (Select All That Apply) A. Atelectasis B. Shortness of breath C. Interstitial and alveolar edema D. Hyaline membranes line the alveoli E. Influx of neutrophils, monocytes, and lymphocytes

A, C, D Rationale: The injury (exudative phase) is the early phase of ARDS when atelectasis and interstitial and alveoli edema occur and hyaline membranes composed of necrotic cells, protein, and fibrin line the alveoli. Together, these decrease gas exchange capability and lung compliance. Shortness of breath occurs but it is not a physiologic change. The increased inflammation and proliferation of fibroblasts occurs in the reparative or proliferative phase of ARDS, which occurs 1 to 2 weeks after the initial lung injury.

Which conditions predispose a patient to acute respiratory distress syndrome (ARDS) with an indirect lung injury? Select all that apply. A. Sepsis B. Bacterial pneumonia C. Opioid drug overdose D. Severe massive trauma E. Aspiration of gastric contents

A, C, D Rationale: Sepsis caused by gram-negative bacteria can predispose patients to the development of acute respiratory distress syndrome (ARDS) with an indirect lung injury. Excessive use of opioid drugs can indirectly lead to an acute respiratory condition. Indirect injury to the lung by a severe massive trauma caused by a head injury can also lead to ARDS. Patients with lung infections such as bacterial or viral pneumonia are directly at risk for ARDS. Aspiration of gastric content into the lungs causes direct infections leading to ARDS or other lung problems.

A critically ill patient with acute respiratory failure is being treated for stress ulcers. What actions are included in the management of the patient's condition? Select all that apply. A. Enteral nutrition B. Strict hand washing C. Oral care and hygiene D. Usage of anti-ulcer agents E. Correction of predisposing conditions

A, D, E Rationale: Enteral feeding should be initiated early to prevent mucosal damage. Stress ulcers can be managed with the use of anti-ulcer agents such as pantoprazole (a proton pump inhibitor) and sucralfate (a mucosal-protecting agent). Stress ulcers can also be managed by taking corrective actions to handle predisposing conditions such as hypotension, shock, and acidosis. Strict hand washing and frequent oral care are strategies to prevent ventilator-associated pneumonia.

The nurse is caring for a patient with decreased oxygenation that does not respond to elevation of the head of the bed. Which is the most appropriate position to improve oxygenation in a patient to recruit more alveoli? A. Prone position B. Tripod position C. Supine position D. Lateral position

A. Rationale: Prone, or face down, position is advised for patients who do not respond when placed in any other position during oxygenation. This position offers better perfusion to ventilation match. Tripod positioning helps to increase chest and lung expansion and decrease efforts to breathe. The supine position changes the pleural pressure and predisposes the patient to respiratory failure. Lateral or side-lying positioning is used for patients with disease involving only one lung.

ABG results show a Ph of 7.30 PCO2 of 35, PO2 of 80 and a HCO3- of 17. A nurse interprets this result as: A. Respiratory Acidosis B. Metabolic Acidosis C. Metabolic Alkalosis D. Respiratory Alkalosis

B

Based on the following ABG's analyze the blood gas and determine the type of change needed to a mechanical ventilator to normalize the gas exchange in the patient. Current ventilator settings of SIMV rate 14, tidal volume 600, FiO2 50%, PEEP 8, his respiratory rate was 15, he was maintaining an oxygen saturation of 90% and his peak inspiratory pressures were 22-28. Ph 7.20, PaCo2 60 mmHg, HCO3 26 mEq/L A. Administer an amp of Sodium Bicarbonate B. Increase the ventilator rate to SIMV of 16 C. Decrease tidal volume to 500 D. Decrease the PEEP to 5

B

Mr. D. was being mechanically ventilated. On setting of SIMV rate 14, tidal volume 600, FiO2 50%, PEEP 8, his respiratory rate was 15, he was maintaining an oxygen saturation of 94% and his peak inspiratory pressures were 22-28. His ABG's revealed pH 7.42, PaO2 96, PaCO2 48, and HCO3 29. A. Metabolic Acidosis B. Compensated Respiratory Acidosis C. Respiratory Acidosis D. Compensated Metabolic Alkalosis

B

What complication can a high peak airway pressure used in the mechanical ventilation of a patient with acute respiratory distress syndrome (ARDS) cause? A. Volutrauma B. Barotrauma C. Stress ulcers D. Ventilator-assisted pneumonia (VAP)

B Rationale: Barotrauma results from rupture of over distended alveoli during mechanical ventilation. Critically ill patients with acute respiratory failure are at high risk for stress ulcers. Volutrauma results in alveoli fractures and movement of fluids and proteins into the alveolar spaces. VAP is a frequent complication in ventilated ARDS patients and is due to impaired host defenses, contaminated equipment, invasive monitoring devices, aspiration of gastrointestinal contents, and prolonged mechanical ventilation.

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is accurate? A. "PEEP will push more air into the lungs during inhalation." B. "PEEP prevents the lung air sacs from collapsing during exhalation." C. "PEEP will prevent lung damage while the patient is on the ventilator." D. "PEEP allows the breathing machine to deliver 100% oxygen to the lungs."

B Rationale: By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient

What results in surfactant dysfunction during the injury phase of acute respiratory distress syndrome (ARDS)? A. Decrease in gas exchange capability B. Damage to alveolar type I and II cells C. Engorgement of the peribronchial space D. Ventilation to perfusion (V/Q) mismatch

B Rationale: During the injury phase of acute respiratory distress syndrome (ARDS), the alveolar type I and II cells (which produce surfactant) will be damaged. Along with accumulation of fluid and proteins, this cell damage results in surfactant dysfunction. The hyaline membranes that line the alveoli lead to the decrease in gas exchange capability. An engorgement of the peribronchial and perivascular interstitial space results in interstitial edema. Ventilation to perfusion (V/Q) mismatch results in hypoxemia.

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following medications ordered. Which medication should the nurse discuss with the health care provider before giving? A. Pantoprazole (Protonix) 40 mg IV B. Gentamicin (Garamycin) 60 mg IV C. Sucralfate (Carafate) 1 g per nasogastric tube D. Methylprednisolone (Solu-Medrol) 60 mg IV

B Rationale: Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS.

The nurse suspects that a patient with PEEP is experiencing negative effects of this ventilatory maneuver when which of the following is assessed? A. Increasing PaO2 B. Decreasing blood pressure C. Decreasing heart rate (HR) D. Increasing central venous pressure (CVP)

B Rationale: PEEP increases intrathoracic and intrapulmonic pressures, compresses the pulmonary capillary bed, and reduces blood return to both the right and left sides of the heart. Increased PaO2 is an expected effect of PEEP. Preload (CVP) and cardiac output (CO) are decreased, often with a dramatic decrease in BP.

The nurse caring for a patient with respiratory failure finds that the patient has hypoxemia due to ventilation-perfusion (V/Q) mismatch. What is the primary intervention that the nurse should implement in this case? A. Administer antibiotics as ordered. B. Give oxygen therapy as ordered. C. Administer bronchodilators as ordered. D. Give antisecretary agents as ordered.

B Rationale: The first intervention for any hypoxemia patient is to administer oxygen. Oxygen therapy can reverse hypoxemia caused by V/Q mismatch, because not all gas exchange units are affected. Antibiotics improve V/Q mismatch only in infective conditions of the lung. Bronchodilators improve V/Q mismatch only if bronchospasm is the underlying cause. Anti-secretory agents improve V/Q mismatch only if increased bronchial secretions are the underlying cause.

A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? A. Administration of 100% oxygen by non-rebreather mask B. Endotracheal intubation and positive pressure ventilation C. Insertion of a mini-tracheostomy with frequent suctioning D. Initiation of continuous positive pressure ventilation (CPAP)

B Rationale: The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? A. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. B. The patient has subcutaneous emphysema on the upper thorax. C. The patient has bronchial breath sounds in both the lung fields. D. The patient has a first-degree atrioventricular heart block with a rate of 58.

B Rationale: The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduced

The nurse receives an order to start continuous rotation therapy for a patient admitted with acute respiratory distress syndrome (ARDS). How should the nurse position the patient for best results? A. Allow the patient to lie face down. B. Allow the patient to lie down laterally on either side. C. Allow the patient to sit with arms propped on the over-bed table or on the knees. D. Allow the patient to sit upright with the head of the bed elevated at least 45 degrees.

B Rationale: Patients being considered for continuous lateral rotation therapy (CLRT) are made to lie down laterally while the nurse continuously and slowly turns the patient side-to-side by rotating the actual bed frame less than 40 degrees. The face down (prone) position offers better perfusion to ventilation match, but does not aid in continuous rotation therapy. The patient would sit with his or her arms propped on the over-bed table or on the knees during a breathing technique. The patient is seated upright with the head of the bed elevated at least 45 degrees during a staged cough.

When caring for the patient with acute respiratory distress syndrome (ARDS), the critical care nurse knows that therapy is appropriate for the patient when which goal is being met? A. pH is 7.32 B. PaO 2 is greater than or equal to 60 mm Hg C. No change in PaO 2 when patient is turned from supine to prone position D. Positive end-expiratory pressure (PEEP) increased to 20 cm H 2O caused blood pressure (BP) to fall to 80/40

B Rationale: The overall goal in caring for the patient with ARDS is for the PaO 2 to be greater than or equal to 60mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP usually is increased for ARDS patients, but a dramatic reduction in BP indicates a complication of decreased cardiac output. A positive occurrence is a marked improvement in PaO 2 from perfusion better matching ventilation when the anterior air-filled, nonatelectatic alveoli become dependent in the prone position.

A patient has developed acute respiratory distress syndrome (ARDS) in the intensive care unit. What nursing action will assist in the treatment of this disorder? A. Effective coughing B. Positioning strategy C. Chest physiotherapy D. Hydration and humidification

B Rationale: Positioning strategy during oxygenation has helped patients with acute respiratory distress syndrome (ARDS) show significant improvement. Effective coughing and adequate hydration and humidification help patients mobilize secretions. Chest physiotherapy is suggested for patients with acute respiratory failure who produce sputum of more than 30 mL per day.

A patient with ARDS has a nursing diagnosis of risk for infection. To detect the presence of infections commonly associated with ARDS, what should the nurse monitor? A. Gastric aspirate for pH and blood B. Quality, quantity, and consistency of sputum C. Subcutaneous emphysema of the face, neck, and chest D. Mucous membranes of the oral cavity for open lesions

B Rationale: Ventilator-associated pneumonia (VAP) is one of the most common complications of ARDS. Early detection requires frequent monitoring of sputum smears & cultures & assessment of the quality, quantity, & consistency of sputum. Prevention of VAP is done with strict infection control measures, ventilator bundle protocol, and subglottal secretion drainage. Blood in gastric aspirate may indicate a stress ulcer and subcutaneous emphysema of the face, neck, and chest occurs with barotrauma during mechanical ventilation. Oral infections may result from prophylactic antibiotics & impaired host defenses but are not common.

The nurse is caring for a patient on positive pressure ventilation. What nursing interventions help to maintain cardiac output in this patient? Select all that apply. A. Administer metoprolol B. Administer crystalloid fluids. C. Administer colloid solutions. D. Administer packed red blood cells. E. Increase peak end expiratory pressure (PEEP).

B, C Rationale: If cardiac output falls, it may be necessary to administer crystalloid fluids or colloid solutions to expand the volume and maintain hemodynamic stability. Packed red blood cells are used to increase tissue perfusion. Metoprolol reduces cardiac contractility. PEEP has to be lowered to maintain cardiac output.

Mark Donnelly is a 54 year old patient admitted 2 days ago in severe DT's. Immediately prior to his admission, he vomited, had a seizure, and probably aspirated. His previous medical history includes HTN, COPD, and an MI treated with angioplasty and a stent. According to his wife, he was taking Toprol and Lipitor regularly prior to admission and has smoked a pack a day for the past 30 years. He had been drinking a fifth of vodka daily until 3 days prior to admission when he stopped completely. He is 5'11" and weighs approximately 180 pounds. On arrival in the ED, his BP was 193/124 with a heart rate of 150. He was tremulous, nauseated, and agitated. Lorazepam was started according to CIWA protocol, but he began to vomit and had several seizures. He was sedated with propofol and Zemuron, emergently intubated, ventilated, and transferred to the ICU. On arrival in the ICU, his BP was 80/52. Which of the following statements describe why his blood pressure dropped? A. The patient may have had another MI B. Mr. Donnelly may need fluid volume resuscitation C. Sympathetic stimulation was blocked with Proprofol and Zemuron D. Propofol can cause a period of hypotension E. When the patient vomited a vasovagal response occurred

B, C, D

Support of the respiratory system in the patient with acute respiratory distress syndrome (ARDS) includes which measures? Select all that apply. A. DiureticsSupine positioning B. Oxygen administration C. Lateral rotation therapy D. Hemodynamic monitoring E. Positive pressure ventilation (PPV)

B, C, E Rationale: PPV, oxygenation administration, and lateral rotation therapy provide support specifically to the respiratory system. Diuretics are drugs that assist in maintaining adequate cardiovascular volume. The patient should be placed in a prone, not supine, position. Hemodynamic monitoring is a supportive therapy that monitors the movement of blood and pressure in the cardiovascular system.

The nurse is caring for a patient with acute respiratory distress syndrome (ARDS). What diagnostic findings would be evident in the patient? Select all that apply. A. Increased pulmonary artery wedge pressure B. Decreased compliance on pulmonary function test C. Scattered crackles and rhonchi on chest auscultation D. Increased functional residual capacity on pulmonary function test E. Diffuse and extensive bilateral interstitial and alveolar infiltrates on chest x-ray

B, C, E Rationale: The patient with ARDS may have scattered crackles and rhonchi on chest auscultation due to fluid-filled alveoli and interstitial edema. The pulmonary function test may show decreased compliance. The chest x-ray may show diffuse and extensive bilateral interstitial and alveolar infiltrates. The pulmonary artery wedge pressure does not increase because the cause of ARDS is noncardiac. The pulmonary function test may show decreased functional residual capacity, which refers to the amount of air remaining in the lungs at the end of normal expiration.

Which descriptions are characteristic of hypoxemic respiratory failure? (Select All That Apply) A. Referred to as ventilatory failure B. Primary problem is inadequate O2 transfer C. Risk of inadequate O2 saturation of hemoglobin exists D. Body is unable to compensate for acidemia of increased PaCO2 E. Most often caused by ventilation-perfusion (V/Q) mismatch and shunt F. Exists when PaO2 is 60 mm Hg or less, even when O2 is administered at 60%

B, C, E, F Rationale: Hypoxemic respiratory failure is often caused by ventilation-perfusion (V/Q) mismatch & shunt. It is called oxygenation failure because the primary problem is inadequate oxygen transfer. There is a risk of inadequate oxygen saturation of hemoglobin and it exists when PaO2 is 60 mm Hg or less, even when oxygen is administered at 60%. Ventilatory failure is hypercapnic respiratory failure. Hypercapnic respiratory failure results from an imbalance between ventilatory supply & ventilatory demand & the body is unable to compensate for the acidemia of increased PaCO2.

Mark Donnelly is a 54 year old patient admitted 2 days ago in severe DT's. Immediately prior to his admission, he vomited, had a seizure, and probably aspirated. His previous medical history includes HTN, COPD, and an MI treated with angioplasty and a stent. According to his wife, he was taking Toprol and Lipitor regularly prior to admission and has smoked a pack a day for the past 30 years. He had been drinking a fifth of vodka daily until 3 days prior to admission when he stopped completely. He is 5'11" and weighs approximately 180 pounds. On arrival in the ED, his BP was 193/124 with a heart rate of 150. He was tremulous, nauseated, and agitated. Lorazepam was started according to CIWA protocol, but he began to vomit and had several seizures. He was sedated with propofol and Zemuron, emergently intubated, ventilated, and transferred to the ICU. On arrival in the ICU, his BP was 80/52. Describe what interventions would be implemented in the nursing care plan based on the patient's risk for continued delirium tremens and risk of seizures? A. Keep the head of the bed at 25 degrees to prevent the patient from falling out of bed with a seizure B. Place seizure pads on both sides of the bed C. Administer anti-epileptics such as phenobarbital D. Administer ativan as scheduled E. Monitor the patient for agitation and restlessness

B, D, E

Which patient with the following manifestations is most likely to develop hypercapnia respiratory failure? A. Rapid, deep respirations in response to pneumonia B. Slow, shallow respirations as a result of sedative overdose. C. Large airway resistance as a result of severe bronchospasm. D. Poorly ventilated areas of the lung caused by pulmonary edema

B. Rationale: Hypercapnic respiratory failure is associated with alveolarhypoventilation with increases in alveolar and arterial carbon dioxide (CO2) & often is caused by problems outside the lungs. A patient with slow, shallow respirations is not exchanging enough gas volume to eliminate CO2. Deep, rapid respirations reflect hyperventilation and often accompany lung problems that cause hypoxemic respiratory failure. Pulmonary edema and large airway resistance cause obstruction of oxygenation & result in a V/Q mismatch or shunt typical of hypoxemic respiratory failure.

Based on the following ABG's analyze the blood gas and determine the type of needed intervention to normalize the gas exchange in the patient. Current ventilator settings of SIMV rate 14, tidal volume 600, FiO2 50%, PEEP 8, his respiratory rate was 15, he was maintaining an oxygen saturation of 90% and his peak inspiratory pressures were 22-28. pH 7.17, PaCO2 18 mmHg, HCO3 7 mEq/L, PaO2 100mmHg, Sa O2 99% A. Decrease tidal volume to 500 B. Administer an amp of Sodium bicarbonate C. Treat the patient based on the underlying cause D. Decrease the SIMV rate to 12

C

Mark Donnelly is a 54 year old patient admitted 2 days ago in severe DT's. Immediately prior to his admission, he vomited, had a seizure, and probably aspirated. His previous medical history includes HTN, COPD, and an MI treated with angioplasty and a stent. According to his wife, he was taking Toprol and Lipitor regularly prior to admission and has smoked a pack a day for the past 30 years. He had been drinking a fifth of vodka daily until 3 days prior to admission when he stopped completely. He is 5'11" and weighs approximately 180 pounds. On arrival in the ED, his BP was 193/124 with a heart rate of 150. He was tremulous, nauseated, and agitated. Lorazepam was started according to CIWA protocol, but he began to vomit and had several seizures. He was sedated with propofol and Zemuron, emergently intubated, ventilated, and transferred to the ICU. On arrival in the ICU, his BP was 80/50? Which of the following statements are correct actions based on this current blood pressure of 80/50? A. Utilize a bite block to keep the patients mouth open during mouth care B. The propofol may need to be decreased for a period of time C. The nurse will need to assess tolerance of the patients BP with the head of the bed elevated to 30-45 degrees D. No changes need to occur

C

The nurse is caring for a client for whom the RT has just removed the ET tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via facemask C. Elevate the client for stridor D. Keep the client in a semi to high fowlers position

C

When explaining respiratory failure to the patient's family, what should the nurse use as an accurate description? A. The absence of ventilation B. Any episode in which part of the airway is obstructed C. Inadequate gas exchange to meet the metabolic needs of the body D. An episode of acute hypoxemia caused by a pulmonary dysfunction

C

A patient with respiratory distress is agitated and confused. What is the best nursing action? A. Administer 3 L/minute oxygen via nasal cannula. B. Provide chest physiotherapy and airway suctioning. C. Assess the patient and report findings to the health care provider. D. Administer an intravenous anti-anxiety medication, and then report to the health care provider.

C Rationale: A patient with respiratory distress may have impaired neurologic functioning due to low oxygen supply. Due to impaired neurologic functioning, the patient may have an altered mental status, resulting in agitation and confusion. In such a condition, the nurse should assess the patient and report findings to the primary health care provider immediately in order to provide appropriate treatment. Some antianxiety medications may aggravate respiratory depression; antianxiety medications should be administered only after consulting with the primary health care provider. Providing chest physiotherapy and airways suctioning helps to improve breathing but does not reduce agitation and confusion in the patient. Oxygen therapy can be provided at 3 L/minute after reporting to the primary health care provider.

To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? A. Chest x-ray B. Oxygen saturation C. Arterial blood gas analysis

C Rationale: Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests may also be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure.

A patient is in the exudative phase of acute respiratory distress syndrome (ARDS). What does the nurse determine the function of surfactant will be in this phase? A. Attract neutrophils B. Decrease tidal volume C. Maintain alveolar stability D. Release cellular mediators

C Rationale: During the injury, or exudative phase, of ARDS, the alveolar type I and II cells produce surfactant to prevent alveolar collapse. The inflammatory and immune systems attract neutrophils to the pulmonary interstitium. A decrease in tidal volume is caused by stimulation of the juxtacapillary receptors. The neutrophils release biochemical, humoral, and cellular mediators to produce changes in the lungs.

The nurse suspects the early stage of ARDS in any seriously ill patient who manifests: A. Respiratory acidosis B. Diffuse crackles and rhonchi C. Dyspnea and restlessness D. Decreased PaO2 and an increased PaCO2

C Rationale: Early signs of ARDS are insidious and difficult to detect but the nurse should be alert for any early signs of hypoxemia, such as dyspnea, restlessness, tachypnea, cough, and decreased mentation, in patients at risk for ARDS. Abnormal findings on physical examination or diagnostic studies, such as adventitious lung sounds, signs of respiratory distress, respiratory alkalosis, or decreasing PaO2, are usually indications that ARDS has progressed beyond the initial stages.

In patients with ARDS who survive the acute phase of lung injury, what manifestations are seen when they progress to the fibrotic phase? A. Chronic pulmonary edema and atelectasis B. Resolution of edema and healing of lung tissue C. Continued hypoxemia because of diffusion limitation D. Increased lung compliance caused by the breakdown of fibrotic tissue

C Rationale: In the fibrotic phase of ARDS, diffuse scarring and fibrosis of the lungs occur, resulting in decreased surface area for gas exchange and continued hypoxemia caused by diffusion limitation. Although edema is resolved, lung compliance is decreased because of interstitial fibrosis. Long-term mechanical ventilation is required. The patient has a poor prognosis for survival.

The nurse is performing chest auscultation of a patient who is suspected of having acute respiratory distress syndrome (ARDS). What findings will the nurse document that indicate that the patient is in the early stages of this disorder? A. Crackling sound B. Bronchial breath sounds C. Normal or fine scattered crackles D. Scattered to diffuse crackles and rhonchi

C Rationale: In the initial stage the patient breathes normally; a chest auscultation is normal or may show signs of fine, scattered crackles. A cracking sound heard on inspiration may indicate pulmonary edema. Bronchial breath sounds over the lung periphery often indicate lung consolidation from pneumonia. In the later stages of ARDS, the chest auscultation will reveal scattered to diffuse crackles and rhonchi sounds.

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with: A. obtaining a ventilation-perfusion scan. B. drawing blood for arterial blood gases. C. insertion of a pulmonary artery catheter. D. positioning the patient for a chest x-ray.

C Rationale: Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

A client with a systemic infection from an infected leg wound tells the nurse, "It's getting hard to breathe." What does the nurse suspect this client is at risk for developing? A. Allergic response from antibiotic therapy B. Deep vein thrombosis C. Acute respiratory distress syndrome D. Anemia

C Rationale: Sepsis is the most common cause of acute respiratory distress syndrome. The client has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The nurse should suspect the client is developing acute respiratory distress. Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of acute respiratory distress syndrome.

Arterial blood gas results are reported to the nurse for a 68-yr-old patient admitted with pneumonia: pH 7.31, PaCO2 49 mm Hg, HCO3 26 mEq/L, and PaO2 52 mm Hg. What order should the nurse complete first? A. Administer albuterol inhaler prn. B. Increase fluid intake to 2500 mL per 24 hours. C. Initiate oxygen at 2 liters/minute by nasal cannula. D. Perform chest physical therapy four times per day.

C Rationale: Initiate oxygen at 2 liters/minute by nasal cannula.Rationale: The arterial blood gas results indicate the patient is in uncompensated respiratory acidosis with moderate hypoxemia. Oxygen therapy is indicated to correct hypoxemia secondary to V/Q mismatch. Supplemental oxygen should be initiated at 1 to 3 L/min by nasal cannula, or 24% to 32% by simple face mask or Venturi mask to improve the PaO2. Albuterol would be administered next if needed for bronchodilation. Hydration is indicated for thick secretions, and chest physical therapy is indicated for patients with 30 mL or more of sputum production per day.

A nurse is caring for a patient diagnosed with acute respiratory distress syndrome. The nurse is aware that these patients often will require which intervention? A. Peritoneal dialysis B. Frequent suctioning C. Mechanical ventilation D. Creatinine and blood urea nitrogen (BUN) testing

C Rationale: Patients with acute respiratory distress syndrome likely will require mechanical ventilation to support their respiratory status. Frequent suctioning is not required often, but some suctioning may be required. Peritoneal dialysis and creatinine and BUN testing might be necessary with some level of kidney failure, not respiratory compromise.

When the V/Q lung scan result returns with a mismatch ratio that is greater than 1, which condition should be suspected? A. Pain B. Atelectasis C. Pulmonary embolus D. Ventricular septal defect

C Rationale: There will be more ventilation than perfusion (V/Q ratio greater than 1) with a pulmonary embolus. Pain and atelectasis will cause a V/Q ratio less than 1. A ventricular septal defect causes an anatomic shunt as the blood bypasses the lungs.

A patient with acute hypoxia will have which of the following symptoms? A. Cyanosis B. Clubbed Fingers C. Anxiety D. Fatigue

C, D

The nurse is caring for a patient on mechanical ventilation. What are the nursing interventions that prevent the development of volutrauma in a patient on a ventilator? Select all that apply. A. Sterile techniques B. Strict hand washing C. Smaller tidal volumes D. Pressure-control ventilation E. Mouth care and oral hygiene

C, D Rationale; Volutrauma occurs when large tidal volumes are given to a mechanically ventilated patient. Because of the high tidal volume, the alveoli may become damaged and tear, allowing proteins and fluid to move into the alveolar spaces. This can be prevented by giving smaller tidal volumes or pressure-control ventilation. Strict hand washing, sterile technique during endotracheal suctioning, and frequent mouth care and oral hygiene are helpful to prevent ventilator-associated pneumonia and not volutrauma.

When teaching the patient about what was happening when experiencing an intrapulmonary shunt, which explanation is accurate? A. This occurs when an obstruction impairs the flow of blood to the ventilated areas of the lung. B. This occurs when blood passes through an anatomic channel in the heart and bypasses the lungs. C. This occurs when blood flows through the capillaries in the lungs without participating in gas exchange. D. Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar membranes.

C. Rationale: Intrapulmonary shunt occurs when blood flows through the capillaries in the lungs without participating in gas exchange (e.g., acute respiratory distress syndrome: ARDS or pneumonia). Obstruction impairs the flow of blood to the ventilated areas of the lung in a V/Q mismatch ratio greater than 1 (e.g., pulmonary embolus). Blood passes through an anatomic channel in the heart and bypasses the lungs with anatomic shunt (e.g., ventricular septal defect). Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar membranes in diffusion limitation (e.g., pulmonary fibrosis or ARDS)

The nurse is caring for a patient with acute respiratory distress syndrome (ARDS) that has developed an infection. The primary care provider has ordered a medication that has the potential to be nephrotoxic. Which medication should the nurse monitor closely for toxic effects? A. Fentanyl B. Albuterol C. Vancomycin D. Corticosteroids

C. Rationale: Administration of nephrotoxic drugs, such as vancomycin, to treat acute respiratory distress syndrome (ARDS)-related infections can cause renal failure. Fentanyl is an opioid used for sedation and analgesia that causes nausea and dizziness. Albuterol is a short-acting bronchodilator causing cardiac ischemia if used for a prolonged period. Prolonged use of corticosteroids can cause adrenal insufficiency and worsen any existing hypokalemia caused by diuretics.

The nurse is caring for a 37-yr-old female patient with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers? A. Observe stools for frank bleeding and occult blood. B. Maintain head of the bed elevation at 30 to 45 degrees. C. Begin enteral feedings as soon as bowel sounds are present. D. Administer prescribed lorazepam (Ativan) to reduce anxiety.

C. Begin enteral feedings as soon as bowel sounds are present. Rationale: Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Anti-ulcer agents such as histamine (H2)-receptor antagonists, proton pump inhibitors, and mucosal protecting agents are also indicated to prevent stress ulcers. Monitoring for GI bleeding does not prevent stress ulcers. Ventilator-associated pneumonia related to aspiration is prevented by elevation of the head of bed to 30 to 45 degrees Stress ulcers are not caused by anxiety. Stress ulcers are related to GI ischemia from hypotension, shock, and acidosis.

The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with a blood pressure of 90/60 mm Hg, apical pulse of 110 beats/min, and respiratory rate of 8 breaths/min. Based on the initial assessment findings, the nurse recognizes that the patient is at risk for which type of respiratory failure? A. Hypoxemic respiratory failure related to shunting of blood B. Hypoxemic respiratory failure related to diffusion limitation C. Hypercapnic respiratory failure related to alveolar hypoventilation D. Hypercapnic respiratory failure related to increased airway resistance

C. Hypercapnic respiratory failure related to alveolar hypoventilation Rationale: The patient's respiratory rate is decreased as a result of barbiturate overdose, which caused respiratory depression. The patient is at risk for hypercapnic respiratory failure due to an obtunded airway causing decreased respiratory rate and thus decreased CO2 elimination. Barbiturate overdose does not lead to shunting of blood, diffusion limitations, or increased airway resistance.

A client has a history of COPD: An ABG shows PCO2 of 60 mm Hg, PO2 of 55 mm hg, a Ph of 7.42, and a HCO3-of 33. Based on this blood gas the nurse would implement which of the following: A. Place the patient on room air as oxygen is not needed. B. Have the client rest most of the next 24 hours C. Increase oxygen by nasal cannula from 2 liters to 4 liters D. Document the finding as the only action

D

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the clients airway secretions? A. The client is unable to speak B. the clients airway was last suctioned 2 hours ago C. The client coughs and expectorates a large mucous plug D. The nurse auscultates coarse crackles in the lungs

D

A patient has an ABG of 7.50, PCO2 of 35, PO2 of 80, HCO3 of 33. A nurse interprets this ABG correctly as: A. Metabolic Acidosis B. Respiratory Alkalosis C. Respiratory Acidosis D. Metabolic Alkalosis

D

Mark Donnelly is a 54 year old patient admitted 2 days ago in severe DT's. Immediately prior to his admission, he vomited, had a seizure, and probably aspirated. His previous medical history includes HTN, COPD, and an MI treated with angioplasty and a stent. According to his wife, he was taking Toprol and Lipitor regularly prior to admission and has smoked a pack a day for the past 30 years. He had been drinking a fifth of vodka daily until 3 days prior to admission when he stopped completely. He is 5'11" and weighs approximately 180 pounds. On arrival in the ED, his BP was 193/124 with a heart rate of 150. He was tremulous, nauseated, and agitated. Lorazepam was started according to CIWA protocol, but he began to vomit and had several seizures. He was sedated with propofol and Zemuron, emergently intubated, ventilated, and transferred to the ICU. On arrival in the ICU, his BP was 80/52. Which of the following have pre-disposed Mr. Donnelly to the development of ARDS? A. Hypertension B. Hyperlipidemia C. Smoking D. Aspiration

D

Ventolin ii puffs PO Q4hr PRN chest tightness. A nurse is assessing a patient's medication orders, as his/her patient is complaining of chest tightness. Ventolin is ordered for this type of patient complaint. Based on the therapeutic drug action the nurse would assess which of the following based on the primary medication action Ventolin. A. Auscultate heart sounds for irregularity and a pulse less than 60 beats per minute. B. Assess peripheral pulses for strength and equality bilaterally. C. Assess the patient's level of orientation to person, place and time. D. Auscultate lung sounds for adventitious lung sounds

D

What is the primary reason that hemodynamic monitoring is instituted in severe respiratory failure? A. To detect V/Q mismatches B. To continuously measure the arterial BP C. To evaluate oxygenation and ventilation status D. To evaluate cardiac status and blood flow to tissues

D Rationale: Hemodynamic monitoring with a pulmonary artery catheter is instituted in severe respiratory failure to determine the amount of blood flow to tissues and the response of the lungs and heart to hypoxemia. Continuous BP monitoring may be performed but BP is a reflection of cardiac activity, which can be determined by the pulmonary artery catheter findings. Arterial blood gases (ABGs) are important to evaluate oxygenation and ventilation status and V/Q mismatches.

When planning care for the client who was a victim of a near-drowning, the nurse will include interventions to address: A. Chronic obstructive pulmonary disease. B. Heart failure. C. Chronic renal failure. D. Acute respiratory distress syndrome.

D Rationale: One of the conditions associated with the development of acute respiratory distress syndrome is an inhalation injury sustained from a near-drowning. Not enough information is provided to determine whether the client will develop heart failure or chronic renal failure. The development of chronic obstructive pulmonary disease is not associated with near-drowning.

Which indirect lung injury puts a patient at increased risk for acute respiratory distress syndrome (ARDS)? A. Near drowning B. Aspiration C. Pneumonia D. Severe trauma

D Rationale: Severe trauma, resulting in an indirect injury to the lungs, increases the risk for development of ARDS. Aspiration, bacterial and/or viral pneumonia, and near drowning all are examples of direct lung injuries that can predispose a patient to ARDS.

A nurse is assessing with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? A. Bilateral wheezing B. Inspiratory crackles C. intercostal retractions D. Increased respiratory rate

D Rationale: The earliest detectable sign of ARDS is an increased respiratory rate, which can begin from 1-96 hours after the initial injury to the body. This is followed by increasing dyspnea., air hunger, retractions of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse

The nurse assesses that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory arrest when the patient displays which behavior? A. Cannot breathe unless he is sitting upright B. Uses the abdominal muscles during expiration C. Has an increased inspiratory-expiratory (I/E) ratio D. Has a change in respiratory rate from rapid to slow

D Rationale: The increase in respiratory rate required to blow off accumulated CO2 predisposes to respiratory muscle fatigue. The slowing of a rapid rate in a patient in acute distress indicates tiring and the possibility of respiratory arrest unless ventilatory assistance is provided. A decreased inspiratory-expiratory (I/E) ratio, orthopnea, and accessory muscle use are common findings in respiratory distress but do not necessarily signal respiratory fatigue or arrest.

Which pathophysiologic change occurs in the fibrotic phase of acute respiratory distress syndrome (ARDS)? A. Diseased lung is characterized by dense, fibrous tissue B. Increased fluid accumulation and decreased lung compliance C. Engorgement of the peribronchial and perivascular interstitial space D. Diseased lung is completely remodeled by collagenous and fibrous tissues

D Rationale: The fibrotic phase is the late phase of acute respiratory distress syndrome (ARDS), which occurs two to three weeks after the lung injury. During this phase, the lung is completely remodeled by collagenous and fibrous tissues. During the reparative phase, which begins one to two weeks from the lung injury, the diseased lung appears dense with fibrous tissue, there is an increase in the fluid accumulations, and lung compliance decreases. Engorgement of the peribronchial and perivascular interstitial space occurs within 24 to 48 hours of the lung injury.

Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO2. The nurse knows that this strategy will: A. increase the mobilization of pulmonary secretions. B. decrease the workload of the diaphragm and intercostal muscles. C. promote opening of atelectatic alveoli in the upper portion of the lung. D. promote perfusion of nonatelectatic alveoli in the anterior portion of the lung.

D Rationale: When a patient with ARDS is supine, alveoli in the posterior areas of the lung are dependent & fluid-filled and the heart and mediastinal contents place more pressure on the lungs, predisposing to atelectasis. If the patient is turned prone, air-filled non-atelectatic alveoli in the anterior portion of the lung receive more blood and perfusion may be better matched to ventilation, causing less V/Q mismatch. Lateral rotation therapy is used to stimulate postural drainage and help mobilize pulmonary secretions.

The O2 delivery system chosen for the patient in acute respiratory failure should: A. Always be a low-flow device, such as a nasal cannula or face mask. B. Administer continuous positive airway pressure ventilation to prevent CO2 narcosis. C. Correct the PaO2 to a normal level as quickly as possible using mechanical ventilation. D. Maintain the PaO2 at greater than or equal to 60 mm Hg at the lowest O2 concentration possible.

D. Maintain the PaO2 at greater than or equal to 60 mm Hg at the lowest O2 concentration possible. Rationale: The selected O2 delivery system must maintain partial pressure of O2 in arterial blood (PaO2) at 55 to 60 mm Hg or higher and arterial O2 saturation (SaO2) at 90% or higher at the lowest O2 concentration possible.